Telehealth An effective tool for antibiotic stewardship (URI, C. diff, UTI, and URI)

Jeremy C. Storm, D.O. Internal Medicine, Infectious Disease, Telehealth

President and CEO - Qvidity Telehealth

Objectives

Things that need our attention NOW UTIs Cellulitis C. diff URI

Telemedicine Basics Overview Rules and regulations How to utilize for infection control and antibiotic stewardship

Urinary Tract Infection

Gram negative drug resistance has increased dramatically, and we are now seeing stable outpatients with UTI’s due to ESBL and CRE requiring IV antibiotics

Overuse of antibiotics, especially carbapenems and FQs, will lead to higher rates of gram negative drug resistance

You need to educate your “prescribers” on how to interpret a UA Should ALWAYS do urinalysis WITH microscopy AND culture If NO pyruia (<10 WBC/HPF) then no UTI and no antibiotics Treat if >10 WBC/HPF and symptoms: TMP/SMX, NTFTN, Cefdinir,

Fosfomycin, Cipro, others (think cipro 4th or 5th) Suppressive abx does not work, consider methanamine

C. Difficile Infection Treat if diarrhea and PCR positive

Should not be doing 3 samples or test of cure, PCR has sens/spec ~ 99%

Flagyl ONLY for mild disease, and first episode only Dose is 500 mg TID x 14 days Would not recommend repeated doses due to risk of irreversible

neuropathy and general lack of effectiveness

PO vancomycin LIQUID 125-250 mg QID x 14 days Much cheaper than vancomycin pills Use for moderate-severe illness or 2nd+ episode

PO fidaxomicin (Dificid) 200 mg BID x 10 days $40 with coupon if private insurance

Stool transplant Need to discuss, consider on/after 3rd episode

Upper Respiratory Infection

VIRAL: if sore throat, cough, fever, runny nose, sick contacts DO NOT check for Strep throat DO NOT give antibiotics Supportive care unless concern for Influenza (then treat)

BACTERIAL: sore throat, fever only (no cough, runny nose) Check for Strep, if positive then PCN or Amoxicillin Consider Monospot (young, lymph nodes, sore throat)

Consider allergies as a cause of “recurrent URI”

Cellulitis

NOT HARD!!!

B/L red legs most likely stasis dermatitis (NOT an infection, is due to edema and won’t respond to abx)

Strep cellulitis: unilateral, painful, acute, sick No pimple, sore, or boil Treatment is PCN/Amoxicillin, Cephalosporins Vancomycin is a crappy Strep drug

Staph infection: starts as pimple, sore, or boil I&D more effective than abx alone Combination of I&D and abx > 90% cure Consider having a decolonization protocol if recurrent or pre-op Clinda largely not effective (bactrim/doxy >95% sensitive)

Cellulitis

Diabetic foot ulcer is usually polymicrobial (gram positives, gram negative, anaerobes)

75% of unilateral red extremity (erysipelas) is Strep Almost always monomicrobial 45% Group A Strep 30% Group B Strep 15% Staph, 10% GNR

Vancomycin is inferior to PCN/ceph’s for treatment of Strep

Zosyn is not needed just because patient is diabetic

Treatment of choice for Strep cellulitis is PCN (consider addition of 2nd agent/clindamycin if severe)

Telehealth

Definitions Telemedicine, telehealth, mobile health (mHealth), direct-to-

consumer (DTC), 2-way video, store and forward, secure messaging, remote monitoring, OH MY!

Broadly, telehealth refers to the delivery of care or exchange of information via any method of technology Phone call, text, email, live video, forwarded / downloaded

data, messaging Major definitions

Telemedicine and telehealth: broad, everything mHealth: telehealth via smartphones, laptops, tablets DTC: as it sounds Remote monitoring: devices collecting data 2-way video: requirement for reimbursement

Med City News 2016

The Status of Telemedicine Today

Cheaper, easier, better technologies

Improving reimbursement / payer demand

Increasing physician / hospital acceptance

Rising patient demand

Heightened competition

Society promotion (AMA, ATA, States, etc.)

Easiest way to connect rural patients to specialists

Adoption, Demand, Competition

Today, patients can access physicians immediately, from anywhere, on their smartphones and within minutes

Who’s offering telemedicine? Healthcare systems: Sanford, Avera, Kaiser, Cleveland Clinic,

Mercy, Mayo EVERYONE!

Online doctor networks: MDLive, American Well, Doctors On Demand, Teladoc Contracting with insurers, businesses, healthcare systems Direct to consumer (DTC)

Insurers: UnitedHealth, Blue Cross, Wellpoint, others Providing on own or contracting with doctor networks

Businesses: Home Depot, Boeing, Walgreens, CVS, MANY others

Patient and Payer Demand

Patients Cost, convenience Expectation(s)

Providers Slow to embrace “new”, but are coming around

Patient demand, easy/affordable technology, competition, and reimbursement all drivers

Payers Medicare: CONNECT for Health Act (2016) and Next Gen ACO’s

Employers Many offering telemedicine as a standard/covered service

“Choice, Transparency, Coordination, and Quality among DTC telemedicine websites…”, JAMA Dermatology 5/15/2016

Market Analysis

According to Ken Research, the telehealth market is expected to grow at an annual rate of 17-30% year over year for the next 10 years 2012: $6 billion 2013: $10 billion 2018: $38 billion

The U.S. telemedicine market outlook to 2018 – rising penetration of telecom care and mHealth (Ken Research, 2014)

Market Components Hardware Software Professional services

U.S. Telehealth Market Breakdown 2012-2022, USD Millions

Grand View Research, 2015

Market Analysis

A 2016 sponsored study with over 390 respondents found: Over 2/3 of healthcare facilities / systems report telemedicine is

a TOP priority in 2016 and at an enterprise level The #1 answer for ROI of telemedicine is “Improved Patient

Satisfaction”, with actual financial ROI a lower priority AKA: Healthcare systems utilizing to compete to acquire

patients with less concern for immediate financial gain Barriers (2) - reimbursement, EMR limitations Interestingly, specialty care via telemedicine is more mature

than general / primary care, despite the ease and applicability of the later

Facility and administrative support were greater predictors of program success than funding

2016 U.S. telemedicine benchmark survey; Reach Health

Market Analysis

According to a 2015 Price Waterhouse survey, which involved interviewing over 2,500 executives, doctors, and patients: 2/3 of patients would utilize mHealth, but only 16% of doctors

/ systems currently offer 12 million people received care via telemedicine in 2014,

with the number expected to double year over year 85% of doctors expect mHealth to be a component of their

practice

Primary care in the New Health Economy: Time for a makeover (PwC, 2015)

Program Requirements

Security of platform/technology

HIPAA/privacy, business associate agreements, contracts, terms and conditions

Malpractice insurance

Licensure

State laws

National and specialty standards

Payers

EHR integration

Rules, Rules, Rules

National standards

Specialty standards

State requirements

Who pays

National and Specialty Standards

Largely, the standard of care for telemedicine is the same as the standard of care for in-person visits Healthcare has deemed telehealth to be an acceptable

delivery method for medical care across all specialties Telehealth is NOT inferior to in-person

For some specialties/conditions, telehealth is the STANDARD of care Telestroke

If limitations of the encounter prevent an adequate history, exam, assessment, and plan, then the patient should be seen in person

FSMB Interstate Medical Licensure Compact

“Tele-ID”

Telemedicine has tremendous potential for infection control and antibiotic stewardship, which are now both a CMS requirement

Patients can be seen same day or next day without need to drive hours to see doctor or specialist

Ability for specialists to reach remote clinics, hospitals, and nursing homes for oversight, committees, and patient care

Becoming more and more important given rising rates of drug resistance and national measures to promote effective prescribing

Personal Experience

Bacteremia Sepsis FUO Endocarditis Osteomyelitis Meningitis SSI/Cellulitis Pneumonia AIDS Drug Resistance

UTI Pyelonephritis Tuberculosis Influenza Histoplasmosis Septic Arthritis Sinusitis Discitis Cat Scratch I have no idea, fix it

Collectively, have performed over 3,500 unique, billable, telehealth encounters

Case #1

63 y.o. female with history of lymphedema, diabetes, hypothyroidism, hypertension, hyperlipidemia, and obesity

2 days of worsening left LE redness, warmth, pain, fatigue, and malaise Prescribed Keflex 500 mg QID yesterday but today worse Meds: Lisinopril, Amlodipine, Synthroid, Metformin, Glipizide

4 prior episodes of cellulitis and 2 hospitalizations (2013, 2015)

Back in PCP office, urgent referral requested She lives 180 miles from ID specialist

Case #1

Telehealth visit set up within 30 minutes

Patient reports a history of Penicillin allergy (hives) and does report feeling a little itchy today

Prior episodes typically required IV antibiotics for 1-2 weeks prior to resolution

Although she does not feel well, her vitals are stable and her labs are “acceptable” WBC 14,000, creatinine 1.2 (baseline), lytes WNL

Case #1

Case #1

Case #1

Telemedicine visit same day GT-99205

IV antibiotic (daptomycin, telavancin, vancomycin) x 1-2 weeks Will receive at PCP office, which also doubled as an urgent care

PICC/Midline/Peripheral IV ok

Weekly CBC, BMP faxed to me

Follow up in 1 week: 90% better, feeling well, transitioned to oral doxycycline 100 mg BID for suppression

Case #2

74 y.o. female with a history of hypertension and atrial fibrillation presents with 1 days of urinary frequency, urgency, hesitancy, and burning History of occasional UTI’s, 1-2/year, and an admission for

pyelonephritis in 2005 Recently treated with ciprofloxacin 2 weeks prior – “symptoms

got better but didn’t completely go away” Meds: metoprolol, coumadin

Repeat UA/micro with >100 WBC, culture pending CBC normal, creatinine 1.9 (baseline, CrCl 30)

Telemedicine consultation requested Patient lives 80 miles away

Case #2

Telehealth visit same day (GT-99204)

Patient reports palpitations on cipro

Culture from 2 weeks ago reviewed: Susceptible to bactrim, nitrofurantoin, ertapenem Resistant to ancef, rocephin, gent, cipro, augmentin “ESBL”

Rx’d PO fosfomycin 3 g QOD x 3 doses Why not bactrim? Why not nitrofurantoin?

Follow-up visit via telemed in 2 weeks - symptoms resolved Do you do a repeat UA/culture?

Case #3

81 y.o. male with history of CAD, dementia, nursing home resident, with a 1.5 year history of worsening lesion “infection” on thigh No allergies Takes ASA, lipitor, lisinopril

Cultures of thigh with Strep, MSSA, Proteus, Pseudomonas

Prescribed multiple courses of PO abx Bactrim, keflex, cipro, augmentin

Telemedicine visit requested, non-emergent

Case #3

Case #3

Saw same day via SNF nurse’s smartphone Billable (GT-99203)

What do you do?

Refer to Derm!!! That is likely cancer and NOT an infectious disease

Case #4

15 female with sore throat, fatigue, cervical lymphadenopathy Rapid Strep + Treated with amoxicillin, but developed rash, changed to

azithromycin

Now with persistent fatigue, slight sore throat, diarrhea Rapid Strep positive C. diff positive Still with exudates ? What to treat

Case #4

Case #4

Check monospot! Classic presentation of Mono (fatigue, tonsillar exudates,

cervical lymphadenopathy in acute phase, rash with amoxicillin)

And…her C. diff PCR is positive PO flagyl 500 mg TID x 14 days or PO vancomycin liquid 125

mg QID x 14 days DO NOT need to check test of cure if asymptomatic (formed

stools)

Take Home Points

Appropriate antibiotic prescribing (or limiting inappropriate use/misuse) is the next big thing MDR (ESBL, CRE, Colistin resistance) is our current reality

If no pyruria (>10 WBC/HPF for urine micro) then no UTI and therefore no antibiotics

If sore throat, fever, cough, runny nose then no rapid Strep test or antibiotics

If C. diff, treat 14 days and if recurrent use vancomycin liquid or stool transplant

Cellulitis is most likely Strep (75%) or Staph (15%)

Telemedicine is now affordable, easy to deploy, and can be a great tool to connect patients with providers and specialists to remote/rural settings. ESPECIALLY FOR INFECTIOUS DISEASE

Thank You!